Suicide – Temperament and Treatment

The question is whether some people are more prone to suicide than others? If so, the challenge is to recognize these people and provide help as early as possible. But what kind of help is needed?

Are some people more susceptible to suicide than others? Suicide is very complex, of course, and involves many factors.

Mental health disorders, especially depression and substance abuse, are most closely linked to suicide. Depression doesn’t necessarily lead to suicide, only about 25%-30% of people suffering from depression attempt suicide, but 90% of those who do attempt suicide experience depression beforehand. 1

Males die are four times more likely to die from a suicide attempt than females, but women attempt suicide three times as much as men. 1

A 2005 review of published studies on suicide found that much of the research found hopelessness, neuroticism and introversion related to the incidence of suicide. 2

A 2008 Zurich study found that most depressed people don’t attempt suicide. The 25% that do had a combination of externalizing traits and internalizing traits. 3

Impulsivity

A number of studies tie impulsivity to suicide. In people that think things through, the suicidal impulse will usually pass.

One long term study followed impulsive toddlers for decades. Impulsive three year olds had an increased risk for attempted suicide by the time they were 21. 4

Another study found that impulsivity was a key factor in both attempted and completed suicide. 5

Psychotherapy for regulating emotions

In psychotherapy patients engage in a conscious effort to reflect on their own feelings and thoughts. People often experience powerful emotions that put all rational thought out of the game. They run the risk of acting impulsively in a situation they really should have thought twice about. The technique of psychotherapy is to train self-awareness, or the ability to reflect on our “inner lives” and emotional responses, so they lose some of their impulsive force.

Trauma and various types of neglect may cause poor skills regarding the ability to understand, tolerate and examine our impulses and impressions in difficult situations. Thus, there is a risk of acting too quickly on the emotional turbulence instigated by negative ideas, and the risk of doing something rash is of course present.

Aggression

Suicide is an aggressive act. Research has found that those who were often involved in physical fights often had violent (and so more successful) suicide attempts. They were more likely to have been arrested or have a criminal record and a study in South Africa found that conduct disorder was the most common diagnosis in suicidal adolescents. 5

Aggressive feelings and actions in children treated at a child guidance clinic turned out to be a good predictor of those who later committed suicide. 5

Alcoholism increases aggression in those who have committed suicide and adult men who have committed suicide were found to have high spontaneous and reactive aggression scores. 5

Aggression isn’t always physical or overt. Defensiveness, being reactive, manipulative or driven for certain outcomes are examples of aggression too.

In many cases, a distinction is made between reactive and proactive aggression, whereupon both categories are associated with increased suicide risk. Reactive aggression is often a stable tendency to get angry in the face of frustrations, obstacles or provocations. In such situations one allow anger and outlet in negative actions. (Dodge, 1991)12 This form is overlapping with other terms such as “hostile aggression” and “emotional aggression”. (Berkovitz, 1993)13.

Reactive aggression is characterized by

• “warm-blooded” – Easy emotionally activated.
• Often captured by the moment – “boiling over” emotionally – the feelings can’t be regulated properly so the overwhelming emotions translates into an attack – with intent to harm.
• Not thinking clearly, but psychologically caught in the violent impulse.
• High risk of rejection (rejected). Interprets signals from the other with a negative trend (misinterpret).
• Narrow or compromised ability to interpret the situation. Strong tendencies for suspicion and distrust, which creates distance to others. They often provide a kind of hostile atmosphere.
• Concerned with aggressive images, symbols, language and so on.
• Have low status and lack popularity among peers.
• The prognosis appears to be relatively low and constant.

Proactive aggression is characterized by

• “Cool – calculating aggression”.
• Can lead to high social status in peer groups.
• Egocentric goals. Open aggression when necessary for obtaining their goals.
• Often respected in peer groups. Leadership skills.
The point is that many studies suggest that successful suicide attempt is associated with an aggressive style, which of course also about impulsivity and inability to manage emotions and impulses through reflection and rational consideration.

Introversion

Introversion involves having little preference for the company of other people. Introverts like to focus on one thing at a time and don’t enjoy crowds. Their lesser amount of social bonds may increase feelings of alienation when depressed.

Not all suicidal people are introverted but many suicidal patients have been found to be shyer, less optimistic and have less social supports. 5

Neuroticism

Neuroticism describes people who tend to quickly and easily experience anger, anxiety, depression, guilt and other negative emotions. 5

Neuroticism has been consistently linked to thoughts of suicide, attempted suicide and completed suicides. 5

The long term study that followed children for 21 years also found that high degrees of neuroticism were linked to later suicide attempts. 5

Social Integration

Suicidal people often have poor social integration and social bonds. One study found that depressed people make little eye contact when they’re speaking with others and don’t engage in much nonverbal communication, which accounts for 90% of our interactions with others. Head-nodding, or affirming what someone else is saying is a common way to strengthen communication and social bonding. 6

Suicidal people are also more likely to have experienced destructive environmental influences on social integration such as: 7

Crisis situations or adverse life events

Divorce or separation

Exposure to the suicides of others in the community, home or in the media

Family history of suicide

Family evidence of mental disorder

Incarceration

Firearms in the home

Neglect

Physical or sexual abuse

Substance abuse

Heredity

Considering that exposure to familial suicides and mental disorder influence the risk of suicide, many have wondered whether suicidal tendencies are genetic.

Genetic research has found that some personality traits are partly inherited. Certain genes have been found to be associated with aggression, impulsiveness and negative affectivity, traits that characterize suicidal people.

The 5-HTTLPR gene seems to influence how people handle stress. One study has found that 5-HTTLPR plays a role in mood disorders and violence and aggression in alcoholics and heroin addicts, but the link to increased risk of suicide is not clear.

MAO-A and COMT genes are associated with violence and aggression as well, but don’t show a relation to suicidal behavior.

The SERT gene is associated with anxiety-related personality traits.

All humans have the potential for aggression so creating a strong link to genes and suicide is difficult. Environmental factors seem to be a much stronger predictor of suicidal personality traits and environmental factors affect the expression and evolution of our genes. 5 & 8

Bipolar Disorder and Schizophrenia

Two disorders that do have genetic components are bipolar disorder and schizophrenia.

3% of patients with bipolar disorder die by suicide. 25%-90% make at least one suicide attempt. Hopelessness is the major risk factor associated with suicide by those with bipolar disorder.

20%-40% of schizophrenics make suicide attempts and 10% are succeed. Depression is the major risk factor in schizophrenic suicide. 1

Creative Personalities and Suicide

The suicides of famous artists have dominated the media for hundreds of years. Research does show that creative people, famous or not, does predispose people to depression and suicide.

Artists tend to be more introverted than most and follow their creative impulses.

Bipolar disorder is the most common affliction of creative people. Characterized by manic episodes of high energy, creativity, impulsivity and explosions of thought, these highs are what artists live for.

It’s the lows that follow—severe depressive episodes that deaden the feelings, inspiration and ability of the creative person—that make life unbearable.

Bipolar patients often go off medication that stabilizes their mood because they miss the highs and inspiration that comes with it. Lithium makes many feel deadened compared to the depth of feeling that they’re used to and their work suffers for it. Their creativity seems to be intricately linked to the disorders they endure.

This population of people tends to use alcohol and drugs to self-medicate, exacerbating depressive symptoms in the long run.

Examples

Poets and writers are four times more likely to suffer from affective disorders. Sylvia Plath, Anne Sexton, Ernest Hemingway and Virginia Woolf committed suicide due to their illnesses.

“Mental disorders are not always the greatest risk factors for suicide,” says authors of Reducing Suicide: A National Imperative. 10

In India (and in Indian immigrants), humiliation, shame, economic hardship, failing exams and family disputes are the greatest risk factors for suicide.

In Norway, family strife influences rates of suicide and in Eastern Europe, political and national identity loss has created the highest rate of suicides in the world.

Antidepressants are commonly prescribed to treat depression and suicide. Their effectiveness is ambiguous however. Some pharmaceutical companies have not reported the effectiveness of placebos in relation to the drugs. In some cases, placebos have worked just as effectively as an antidepressant almost half the time.

That’s not to say that antidepressants don’t help many. They can be life-savers for some. People react in unpredictable ways to antidepressants: what works for one person wont’ work for the next. Side effects are another drawback of antidepressants.

Finding the proper medication involves several attempts and lots of patience: it takes up to 6 weeks for antidepressant medications to begin to have effect.

80% of the elderly have found relief from depression with medication, psychotherapy or a combination of the two. 12

Recent research has discovered that a combination approach is most effective in older adults and that those who received IPT and the antidepressant nortriptyline were much less likely to experience a recurrence of depressive episodes than those who received medication only or therapy only.

In the end, social support that includes education and self-management skills about depression, substance abuse, child-rearing practices, impulse-control, social involvement, stress management, decision-making, treatment options, positive thinking and lifestyle choices can greatly reduce the incidence of suicide no matter the risk factors involved.

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